الفهرس 
IntroductionOnly 14 pages are availabe for public view
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Abstract
Apical prolapse is a rather frequent encounter either as a primary finding in patients with pelvic organ prolapse or following vaginal hysterectomy. Several operations and different approaches were presented to manage such a problem. One of the most performed procedure is the sacrospinous ligament fixation. In 1892, Zweifel was the first to describe a vaginal vault reconstructive surgery anchoring the prolapsed vault to the sacrotuberous ligament. Amreich and Reichter introduced sacrospinous ligament fixation some 70 years ago. Since then, the operation was a subject to several modifications aiming to make it more effective, easier to perform and free of complications. The vaginal approach is by far the most performed. It has been described using a variety of instruments including blunt, angular Deschamps ligature carrier, the Miya Hook ligature carrier and the Shutt Suture Punch System. The Autosuture Endostitch, which is originally designed for endoscopic surgery, was introduced by Schlesinger in 1997. Quiet recently, vaginal mesh kits were used but rapidly fell in disuse because of mesh related complications.
This study was designed as a randomized controlled study aiming to compare a modified sacrospinous sacrotuberous complex fixation procedure to the conventionally performed sacrospinous fixation. The study was registered in www.trials.gov with the registration number NCT03487328. It was conducted in the period from March 2018 to May 2020 both in the department of Obstetrics & Gynecology of the Ain Shams Faculty of Medicine, Cairo-Egypt, and the Department of Women Health of the Evangelisches Krankenhaus Bethanien- IserlÖhn, Germany.
The modifications advanced are summarized in the following points:
An Apical Approach for the posterior vaginal wall incision rendering the dissection way shorter and easier
The needle is held on the needle holder so that it creates a puncture perpendicular to the ligament and not parallel to it.
Two suspending sutures are made in the sacrospinous-sacrotuberous complex at the intersection of the two ligaments in the medial half of it.
The stability of the suspending sutures is always tested before completing the surgery.
We use PDSII® for the pulley sutures which are long term absorbable sutures intended to convey more strength and stability while avoiding the problem of erosions that are met with the use of permanent non-absorbable sutures
We use a bio mesh made of collagen to strengthen the vaginal skin and prevent its tearing when pulling on the pulley sutures and to convey a better support for the rectovaginal space.
The pulley sutures are made while leaving the upper 2cm. Of the vaginal apex free to avoid tearing within the usually thinned out postmenopausal vaginal skin
When bilateral fixation is needed, the left side is not tightly approximated to the ligament to leave a space for adequate sigmoid and rectosigmoid function
This pilot study included 40 patients with variable degrees of utero-vaginal or vaginal vault prolapse which were randomly assigned to two groups. The first group included 20 patients which were subjected to the modified sacrospinous-sacrotuberous fixation and the second group comprised 20 patients which were subjected to the conventional sacrospinous fixation. Both groups were comparable regarding the demographic data and the basal clinical characteristics.
The modifications we proposed in this study are rendering the procedure safer with better vaginal restorative results and fewer complications. The small number of the study is inherent to the pilot nature of the study and further trials are needed to make the procedure an established surgical one for the treatment of uterovaginal / vaginal vault prolapse.
The results of this pilot study allow us with confidence to reject the Null hypothesis and to state that the modified technique is conveying better stability to the suspended vaginal vault/uterus with a better safety profile regarding less suture eroding events, buttock pains due to nerve entrapment and dyspareunia.